Drivers of household antibiotic use in urban informal settlements in Northern Ghana: Implications for antimicrobial resistance control

Abstract Background Urban informal settlements have been described as the epicenters of frequent antibiotic misuse, which has local and global consequences on the goals of antimicrobial stewardship. The aim of this study was to assess the relationship between knowledge, attitude, and practices of antibiotic use among households in urban informal settlements in the Tamale metropolis of Ghana. Method This study was a prospective cross‐sectional survey of the two major informal settlements in the Tamale metropolis, namely Dungu‐Asawaba and Moshie Zongo. In all, 660 households were randomly selected for this study. Households with an adult and at least a child under 5 years old were randomly chosen. An adult with knowledge of household healthcare practices was selected to respond to a structured questionnaire. Results In all, 291 (44.1%) of the 660 households reported taking at least one type of antibiotic within the last month before the study and 30.9% (204/660) had used antibiotics without a prescription. Information on which antibiotics to use was obtained mostly from friends/family members 50 (24.5%) and were commonly purchased from a medical store or a pharmacy 84 (41.2%), saved up from a previously used antibiotic 46 (22.5%), a friend/family members 38 (18.6%), and drug hawkers 30 (14.7%). Amoxicillin 95 (26.0%) was the most frequently used antibiotic and the commonest indication for antibiotics use was diarrhea 136 (37.9%). Female respondents (odds ratio [OR] = 3.07; 95% confidence interval [CI] = 2.199–4.301; p < 0.0001), larger households (OR = 2.02; 95% CI = 1.337–3.117; p = 0.0011) and those with higher monthly household income (OR = 3.39; 95% CI = 1.945–5.816; p < 0.0001) were more likely to have good knowledge of appropriate antibiotic use and antibiotic resistance. Furthermore, bad attitudes influenced participants' use of antibiotics without prescription (OR = 2.41; 95% CI = 0.432–4.05; p = 0.0009). Conclusion This study exposes the drivers of inappropriate use of antibiotics at the household level, particularly in urban informal settlements. Policy interventions aimed at controlling the indiscriminate use of antibiotics in such settlements could improve the responsible use of antibiotics. Keywords: antibiotic resistance, informal settlements, Tamale, Ghana

settlements are characterized by high population density, poor sanitation, lack of consistent access to clean water, insecure residential status, and high participation in the informal economy. 4,5 These features promote the spread of infectious diseases and the demand for antibiotics. [4][5][6] Antibiotics purchased without prescriptions and from unqualified vendors are common in these informal settlements. Although unacceptable, the economic status of these settlements permits residents to buy antibiotics in bits if they cannot pay for the complete course or from informal sources. 7 The cost of antibiotic resistance to the global economy is significantly huge. In addition to death and disability, prolonged illness results in longer hospital stays, the need for more expensive medicines, and an increased financial burden on those affected. In 2019, an estimated 4.95 million deaths were associated with AMR at a rate of 27.3 deaths per 100,000 across all-age death in western sub-Saharan Africa. 3 This reveals the urgent need to curb antibiotic resistance.  west. 8,9 The metropolis has one of the fastest-growing populations with a current population of 374,744, of which 185,051 are males and 189,693 are females. There are about 35,408 households in the metropolis with an average of 11 members per household. 9 The two major communities of the metropolis which are characteristic of an urban informal settlement per the metropolitan's demography were selected for this study. These communities were Dungu-Asawaba and Moshe Zongo, characterized by many drugs or chemical shops and other informal sales of medicines, compounded with lack of safe and hygienic sanitary facilities.

| Selection of household and participants
The households were selected using a multistage sampling method. First, we purposefully selected the two major suburbs which had the characteristics of urban informal settlement as described by Nadimpalli et al. 4 The second stage involved a random selection of houses or housing units. In each suburb, major streets were used to divide the suburb into quadrants, and an approximately equal number of houses were sampled from each quadrant. Third, household each was randomly selected from each housing unit. Only households with at least a child <5 years old and an adult with knowledge of household healthcare practices were considered for random selection. From each suburb, 330 households were recruited, making a total of 660 for the study. The sample size was calculated using the Cochrane formula (n = Z 2 P (1 − P)/d 2 ). 10 The confidence interval was 95%, the Z statistic was 1.96, and the P was 74.1% from previous studies, 11 which gave a minimum sample size of 326.

| Data collection procedure and study instrument
We searched through available literature and adopted our questionnaire to assess the KAP regarding antibiotic use and resistance among our study participants. 1,5,7,[12][13][14][15][16][17] The questionnaire had sociodemographic, knowledge, attitude, and practice sessions. We calculated the inter-relatedness of the questions in each section using Cronbach's alpha. The reliability scores were 0.72, 0.65, and 0.5 for knowledge, attitude, and practice, respectively. Trained research assistants administered the questionnaire, and when appropriate, the questionnaire was translated into the respondents' native language.
The responses to the knowledge questions were either "True" or "False," or "Yes" or "No," and scored 1 for a correct response. We calculated the knowledge score (K-score) as the number of correct answers out of the 10 questions. Knowledge score was categorized as good or poor based on the mean K-score as described by Bulabula et al. 18 For the attitude scores, each desired answer was scored 1 and the mean score was calculated for each respondent. Those who had an attitude score equal to or above the mean score were classified as having a good attitude and those below the mean score were recorded as bad attitude. For practices, each desired response was also scored 1.

| Data management and analysis
The data were entered into Microsoft excel and later exported into STATA software version 13.1 (Stata) for all statistical analyses.
Data analysis of the KAP study included descriptive and analytic components. Descriptive analysis included frequencies, mean and SD for all scores after checking for their normal distribution. We reported frequencies of correct answers in the knowledge section and expected answers for the attitude and practice sections.
For the analytic component, the relationship between baseline characteristics, attitudes, and practice with K-score using the chisquare test. We also compare the proportions of desired attitude and practice between the K-scores. Furthermore, we used logistic regression models to identify predictors of antibiotic selfmedication and assess the correlation between knowledge and sociodemographic characteristics. A p < 0.05 was considered statistically significant.  Informed consent was obtained from all participants after explaining the study objectives, risks, benefits, right to refuse, and confidentiality.

| Ethical considerations
Participation was purely based on volunteerism. The identity and data of participants were kept confidential.

| Characteristics of the respondents and households
The mean (SD) age of the household respondents was 28 (2.3) years.
The monthly household income (MHI) in Ghana Cedis was less than 1000 in 244 (37.0%) households, whereas the remaining earned between 1000 and 3000 (Table 1). purchased with a prescription. Although 508 (77.0%) believed antibiotics can be used to cure flu, 280 (42.4%) others thought they can be used to treat headaches and cough. In addition, 394 (59.7%) knew that antibiotics will not help recover quickly from a fever. Four hundred and ninety-one (74.4%) answered that AMR is the failure of an antibiotic to kill germs and 421 (63.8%) knew that resistance to antibiotics is a serious health challenge in Ghana. Additionally, 544 (82.4%) were aware that misuse of antibiotics is a major cause of resistance and 401 (60.8%) others revealed that one must not share antibiotics with household members for the same conditions. In all, a greater number of respondents 441 (66.8%) answered correctly that many infectious diseases will be difficult to treat when there is resistance to existing antibiotics.

| Household history of antibiotic use
T A B L E 1 Household characteristics, attitudes, and practice of antibiotic use and antibiotic resistance of respondents versus knowledge level.    (Figure 3).

| Factors associated with antibiotic use and antibiotic resistance knowledge
Regarding knowledge, older respondents, female respondents, larger household size, respondents with higher educational attainment, and households with higher monthly income were more likely to have good knowledge of appropriate antibiotic use and antibiotic resistance (

| Factors associated with antibiotic self-medication (use of antibiotics without prescription)
The logistic regression showed that household respondents with high educational levels, poor knowledge, and bad attitude were more likely to use antibiotics without prescription (self-medication), whereas female respondents, older respondents, those from small household sizes, and those with high MHI and bad attitudes were less likely to self-medicate as shown in Table 2.

F I G U R E 3
Proportions of responses to attitude assessment on antibiotic use and antibiotic resistance.
T A B L E 2 logistic regression analysis of household respondent characteristics with knowledge of appropriate antibiotic use and antibiotic resistance and antibiotic self-medication.  holds that reported the use of antibiotics within a month before this study was relatively higher compared with other studies that reported on antibiotic use in the general population. 4,7,17,19 However, this is lower than the 66% and 73% of respondents elsewhere in Ghana, 15 the 81.25% in Pakistan, 20 and 60.7% in Cameroun. 21  propel the community demand for antibiotics. Access to antibiotics without prescription is common in many LMICs. 1,2,4,17,18,26,27 This has resulted in the indiscriminate use of antibiotics and its associated rise in antibiotic resistance in such countries. 4,5 Antibiotic use without prescription (self-medication) was associated with older respondents, those with higher educational levels, low MHI, larger households, and poor knowledge. Similar to this study, other studies have found an association between socioeconomic status and antibiotic self-medication. 18  reported that self-medication with antibiotics is associated with knowledge and that persons with low knowledge were more likely to

ACKNOWLEDGMENTS
We acknowledge all the households who participated in the studies.
We are also grateful to all our field staff.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
Data will be made available upon reasonable request from the corresponding author.

TRANSPARENCY STATEMENT
The lead author Ezekiel K. Vicar affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; VICAR ET AL.